Senior Quality Verification Specialist

Gainwell Technologies

. Conduct independent quality and compliance reviews of member and provider interactions involving account access requests and provider EFT change requests .

Posted 10/23/2026full-timeRemote • Texas • United StatesSenior💰 $63,000 - $90,000 per yearWebsite

About the role

Key responsibilities & impact

Conduct independent quality and compliance reviews of member and provider interactions involving account access requests and provider EFT change requests
Reassess completed verification reviews using an “audit-the-auditor” approach
Retest evidence, controls, decisions, documentation, and handoffs from intake and authentication through verification, approval, processing, communication, escalation, and closure
Apply random, risk-based, targeted, and retrospective review methodologies
Retest controls supporting identity, representative authority, affiliation, ownership, authentication, verification responses, call controls, scripts, disclosures, and documentation standards
Assess account access requests and provider EFT changes for accuracy, professional communication, authorized representative handling, documentation completeness, escalation, and follow-up compliance
Test high-risk request controls, including supporting evidence, signatures, organizational relationships, email and website validations, banking information, ownership verification, exceptions, and portal access administration
Prepare evidence-based reports documenting scope, sampling methods, findings, risks, severity, rationale, and recommendations
Present results to compliance leadership, business leaders, and process owners
Immediately escalate suspected fraud, privacy or security concerns, unauthorized changes, systemic control failures, and significant compliance issues
Track remediation, support root-cause analysis, validate corrective-action effectiveness, and escalate overdue or ineffective actions
Maintain complete, traceable review evidence in accordance with retention, access, and legal hold requirements
Translate trends and findings into recommendations for training, procedures, workflows, system enhancements, automation, and control improvements
Coach Verification Specialists, support onboarding and knowledge sharing, identify training needs, and recommend updates to procedures, scripts, checklists, and reference materials
Support approved verification activities and operational follow-up while maintaining separation from reviews of the same cases
Maintain objectivity, avoid conflicts of interest, and route cases with direct involvement to an independent reviewer

Requirements

What you’ll need

Five or more years of experience in member services, member or provider verification, provider enrollment, healthcare operations, compliance operations, or a related field, including quality reviews or operational control testing across multi-step workflows
Ability to apply policies and procedures, independently reassess completed verification reviews, retest underlying controls and handoffs across the account access and provider EFT change-request lifecycle, reconcile conflicting information, and document objective, evidence-based conclusions
Working knowledge of member and provider authentication, representative verification, information protection, fraud indicators, approval and processing controls, escalation, documentation integrity, and cross-team handoffs
Strong analytical, organizational, and time-management skills
Clear written and verbal communication; ability to prepare findings reports, present results and risk-based recommendations to leadership and operational teams, guide and coach Verification Specialists, promote consistent review standards, and partner on people, process, and technology improvements
Proficiency with Microsoft Office and SharePoint
Ability to use case-management systems, approved records repositories, and interaction-recording or quality-review platforms
Experience in Medicaid member services or provider operations, quality reviews of member and provider interactions related to account access and provider EFT change requests, or end-to-end reviews of EFT, portal administrator access, or other high-risk provider changes (preferred)
Experience with independent second-level quality reviews, risk-based sampling, finding classification, root-cause analysis, corrective-action validation, cross-functional trend reporting, and recommendations for people, process, or technology improvements (preferred)
Familiarity with CXone or comparable interaction-review platforms, member and provider systems of record, and business-verification tools (preferred)
Video cameras must be used during all interviews and during the initial week of orientation
Photo will be taken during screening for verification in all steps of the recruitment process
Must join screenings, interviews, and meetings from a quiet location with a stable internet connection

Benefits

Comp & perks

Fully remote options from most US locations and territories
Work flexibility
Learning and career development
Flexible vacation policy
401(k) employer match
Comprehensive health benefits
Educational assistance
Leadership and technical development academies